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CHANDIGARH UNIVERSITY Institute of Distance and Online Learning Course Development Committee Prof. (Dr.) R.S.Bawa Pro Chancellor, Chandigarh University, Gharuan, Punjab Advisors Prof. (Dr.) Bharat Bhushan, Director – IGNOU Prof. (Dr.) Majulika Srivastava, Director – CIQA, IGNOU Programme Coordinators & Editing Team Master of Business Administration (MBA) Bachelor of Business Administration (BBA) Coordinator – Dr. Rupali Arora Coordinator – Dr. Simran Jewandah Master of Computer Applications (MCA) Bachelor of Computer Applications (BCA) Coordinator – Dr. Raju Kumar Coordinator – Dr. Manisha Malhotra Master of Commerce (M.Com.) Bachelor of Commerce (B.Com.) Coordinator – Dr. Aman Jindal Coordinator – Dr. Minakshi Garg Master of Arts (Psychology) Bachelor of Science (Travel &Tourism Management) Coordinator – Dr. Samerjeet Kaur Coordinator – Dr. Shikha Sharma Master of Arts (English) Bachelor of Arts (General) Coordinator – Dr. Ashita Chadha Coordinator – Ms. Neeraj Gohlan Academic and Administrative Management Prof. (Dr.) R. M. Bhagat Prof. (Dr.) S.S. Sehgal Executive Director – Sciences Registrar Prof. (Dr.) Manaswini Acharya Prof. (Dr.) Gurpreet Singh Executive Director – Liberal Arts Director – IDOL © No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise without the prior written permission of the authors and the publisher. SLM SPECIALLY PREPARED FOR CU IDOL STUDENTS Printed and Published by: TeamLease Edtech Limited CONTACT NO:- 01133002345 For: CHANDIGARH UNIVERSITY 3 Institute of Distance and Online Learning CU IDOL SELF LEARNING MATERIAL (SLM)

First Published in 2021 All rights reserved. No Part of this book may be reproduced or transmitted, in any form or by any means, without permission in writing from Chandigarh University. Any person who does any unauthorized act in relation to this book may be liable to criminal prosecution and civil claims for damages. This book is meant for educational and learning purpose. The author of the book has/have taken all reasonable care to ensure that the contents of the book do not violate any existing copyright or other intellectual property rights of any person in any manner whatsoever. In the event, Authors has/ have been unable to track any source and if any copyright has been inadvertently infringed, please notify the publisher in writing for corrective action. CONTENT 4 CU IDOL SELF LEARNING MATERIAL (SLM)

Unit 1: Child Psychopathology..................................................................................................6 Unit 2: Nature OF Child Psychopathology..............................................................................28 Unit 3: Mental Retardation Part I.............................................................................................62 Unit 4: Mental Retardation Part Ii ...........................................................................................97 Unit 5: Behavioural Disorders Part I .....................................................................................122 Unit 6: Behavioural Disorders Part Ii ....................................................................................154 Unit 7: Disruptive Behaviour Disorders Part I ......................................................................175 Unit 8: Disruptive Behaviour Disorders Part Ii .....................................................................201 Unit 9: Conduct DISORDER Part I .......................................................................................220 Unit 10: Conduct DISORDER Part Ii ....................................................................................236 5 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 1: CHILD PSYCHOPATHOLOGY STRUCTURE 1.0 Learning Objectives 1.1 Introduction 1.2 Historical Perspective of Child Psychopathology 1.3 Causes 1.4 Stress 1.5 Temperament 1.6 Neurology and Etiology 1.7 Agenesis of The Corpus Callosum And Etiology 1.8 Treatment 1.9 Psychotherapy Treatments for Common Psychological Disorders in Children 1.10 Future of Child Psychopathology 1.11 Theory and Research 1.12 Summary 1.13 Keywords 1.14 Learning Activity 1.15 Unit End Questions 1.16 References 1.0 LEARNING OBJECTIVES After studying this unit, student will be able to: • Explain psychopathology with emphasis on child psychopathology and its causes and treatments. • Explain stress and temperament can cause child psychopathology • Explain is neurology and etiology. • Discuss agenesis in corpus callusom and etiology 6 CU IDOL SELF LEARNING MATERIAL (SLM)

1.1 INTRODUCTION An early use of the term \"psychopathology\" dates back to 1913 when the book General Psychopathology was first introduced by Karl Jaspers,1 a German/Swiss philosopher and psychiatrist. This new framework for understanding the mental experience of individuals followed a long history of varied attempts at making meaning out of \"abnormal experiences.\" Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. How do we currently define psychopathology? In short, this discipline can be understood as an in-depth study of problems related to mental health. Just like pathology is the study of the nature of disease (including causes, development, and outcomes), psychopathology is the study of the same Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. This study of mental illness can include a long list of elements: symptoms, behaviours, causes (genetics, biology, social, psychological), course, development, categorization, treatments, strategies, and more. In this way, psychopathology is all about exploring problems related to mental health: how to understand them, how to classify them, and how to fix them. Because of this, the topic of psychopathology extends from research to treatment and covers every step in between. The better we can understand why a mental disorder develops, the easier it will be to find effective treatments 1.2 HISTORICAL PERSPECTIVE OF CHILD PSYCHOPATHOLOGY The Field of psychopathology is of relatively recent origin. Prior to the 20th century, psychopathology was concerned almost exclusively with adult behavioural disorders. Child behaviour disorders, though occasionally acknowledged, received little concerted attention. In all likelihood, this state of affairs resulted from then the prevailing viewpoint of children being simply little adults or homunculi (“little men”). Children were not thought to possess “personalities” of their own; rather they were viewed as miniature adults, evincing problems 7 CU IDOL SELF LEARNING MATERIAL (SLM)

similar to adults, and benefitting from reasoned advice much like their adult counterparts (Aries, 1962). A “child psychopathology,” let alone a “child psychopathology,” was non- existent. Although it is obvious to any student of child development that behaviour, whether “normal” or “abnormal,” must be examined within a developmental context, it is only recently that child psychiatry and clinical child psychology have paid more than lip service to this notion. Both theory and nomenclature were originally adapted from work with adults, and the important changes in behaviour and cognitive capacity that occur as a function of physical maturation and psychological development were largely overlooked. Instead, attempts were made to extend adult models downward, and theories of adult psychopathology were unsuccessfully adapted to childhood problems. Signs of psychopathology Signs of psychopathology vary depending on the nature of the condition. Some of the signs that a person might be experiencing some form of psychopathology include: • Changes in eating habits • Changes in mood • Excessive worry, anxiety, or fear • Feelings of distress • Inability to concentrate • Irritability or anger • Low energy or feelings of fatigue • Sleep disruptions • Thoughts of self-harm or suicide • Trouble coping with daily life • Withdrawal from activities and friends Scope of Psychopathology: Just as the scope of psychopathology is broad ranging from research to treatment, so too is the list of types of professionals who tend to be involved in the field. At the research level, you will find research psychologists, psychiatrists, neuroscientists, and others trying to make sense of the different manifestations of mental disorders seen in clinical practice. 8 CU IDOL SELF LEARNING MATERIAL (SLM)

At the clinical level, you will find many types of professionals attempting to apply the diagnostic systems that are in place to provide effective treatments to individuals living with psychopathology. These can include the following and more: • Clinical psychologists • Counsellors • Criminologists • Marriage and family therapists • Nurse practitioners • Psychiatric nurses • Psychiatrists • Social workers • Sociologists Identifying Psychopathology How do psychologists and psychiatrists decide what extends beyond normal behavior to enter the territory of \"psychopathology?\" Psychiatric disorders can be conceptualized as referring to problems in four areas: deviance, distress, dysfunction, and danger. For example, if you were experiencing symptoms of depression and went to see a psychiatrist, you would be assessed according to a list of symptoms (most likely those in the DSM-5): Deviance: This term refers to thoughts, emotions, or behaviours that deviate from what is common or at odds with what is deemed acceptable in the society. In the case of depression, you might report thoughts of guilt or worthlessness that are not common among other people. Distress: This symptom refers to negative feelings either felt within a person or that result in discomfort in others around that person. In the case of depression, you might report extreme feelings of distress over sadness or guilt. Dysfunction: With this symptom, professionals are looking for the inability to achieve daily functions like going to work. In the case of depression, you might report that you can't get out of bed in the morning or that daily tasks take you much longer than they should. Danger: This term refers to behaviour that might put you or someone else at some type of detrimental risk. In the case of depression, this could include reporting that you are having thoughts of suicide or harming yourself. In this way, you can see that the distinction between normal versus psychopathological behavior comes down to how issues are affecting you or the people around you. 9 CU IDOL SELF LEARNING MATERIAL (SLM)

Often it is not until things come to a crisis point that a diagnosis is made when someone comes in contact with a medical or mental health professional. 1.3 CAUSES There is not a single cause for psychopathology. There a number of factors that can increase the risk of mental illness, including: Biological factors Consist of anything physical that can cause adverse effects on a person's mental health. This includes genetics, prenatal damage, infections, exposure to toxins, brain defects or injuries, and substance abuse. Chronic medical conditions Living with a chronic illness can be debilitating; both physically and mentally. The toll it can take on your body is bound to affect your ability to cope with psychological and emotional stress. Not only can a chronic illness make it impossible to do the things you enjoy, it can also rob you of a sense of hope for the future. Family members with mental illness Looking after a family member with a mental illness can be an extremely stressful time and coping with the stress may rouse various reactions such as somatic problems (migraines, loss of appetite, fatigue, insomnia), cognitive and emotional problems (anxiety, depression, guilt, fear, anger, confusion) and behavioural. Feelings of isolation Mental and physical health are interconnected. Social isolation's adverse health consequences range from sleeplessness to reduced immune function. Loneliness is associated with higher anxiety, depression, and suicide rates. Lack of social support Poor social support has been linked to depression and loneliness and has been shown to alter brain function and increase the risk of the following: Alcohol use. Cardiovascular disease. Depression. Substance of alcohol use Substance abuse may sharply increase symptoms of mental illness or even trigger new symptoms. Abuse of alcohol or drugs can also interact with medications such as antidepressants, anxiety medications, and mood stabilizers, making them less effective at managing symptoms and delaying your recovery. 10 CU IDOL SELF LEARNING MATERIAL (SLM)

Traumatic or stressful experiences When you experience a traumatic event, your body’s defences take effect and create a stress response, which may make you feel a variety of physical symptoms, behave differently and experience more intense emotions. It is also important to realize that mental health can change over time. The Centres for Disease Control and Prevention (CDC) suggests that 50% of all people will be diagnosed with a mental illness at some point in their life. Types Some of the different types of psychopathology include, but are not limited to: • Anxiety disorders • Bipolar disorders • Depressive disorders • Disruptive, impulse-control, and conduct disorders • Dissociative disorders • Eating disorders • Neurocognitive disorders • Neurodevelopmental disorders • Obsessive-compulsive disorders • Personality disorders • Schizophrenia spectrum and other psychotic disorders • Sleep disorders • Somatic symptom disorders • Substance-related disorders • Trauma- and stressor-related disorders 1.4 STRESS Emotional stress or trauma in the parent-child relationship tends to be a cause of child psychopathology. First seen in infants, separation anxiety in root of parental-child stress may lay the foundations for future disorders in children. Stress is one of the strongest causal predictors of a wide range of psychopathology, and the role of stress is given prominence in most theoretical accounts of the cause and maintenance of psychopathological disorders. Nevertheless, it is increasingly understood that there are wide differences in individuals' sensitivity, or reactivity, to stress. Further, there is now a large amount of evidence suggesting that some individuals may become increasingly sensitized to stress over time. These joint processes of stress sensitivity and stress 11 CU IDOL SELF LEARNING MATERIAL (SLM)

sensitization have enormous implications for understanding individual differences in risk for the onset and maintenance of psychopathology. So stress can affect anyone who feels overwhelmed — even children. In pre-schoolers, separation from parents can cause anxiety. As kids get older, academic, and social pressures (especially from trying to fit in) create stress. Many children are too busy to have time to play creatively or relax after school. Kids who complain about all their activities or who refuse to go to them might be overscheduled. Talk with your kids about how they feel about extracurricular activities. If they complain, discuss the pros and cons of stopping one activity. If stopping isn't an option, explore ways to help manage your child's time and responsibilities to lessen the anxiety. Children’s stress may be intensified by more than just what's happening in their own lives. Do your children hear you talking about troubles at work, worrying about a relative's illness, or arguing with your spouse about financial matters? Parents should watch how they discuss such issues when their kids are near because children will pick up on their parents' anxieties and start to worry themselves. World news can cause stress. Children who see disturbing images on TV or hear talk of natural disasters, war, and terrorism may worry about their own safety and that of the people they love. Talk to your kids about what they see and hear, and monitor what they watch on TV so that you can help them understand what's going on. Also, be aware of complicating factors, such as an illness, death of a loved one, or a divorce. When these are added to the everyday pressures kids face, the stress is magnified. Even the most amicable divorce can be tough for children because their basic security system — their family — is undergoing a big change. Separated or divorced parents should never put children in a position of having to choose sides or expose them to negative comments about the other spouse. Also realize that some things that aren't a big deal to adults can cause significant stress for children. Let your child know that you understand they're stressed and don't dismiss their feelings as inappropriate. Influence of childhood stress on brain structures: neuroimaging studies Neuroimaging techniques have been improving and becoming more accessible. Such techniques are valuable tools for unravelling the neurobiological underpinnings of psychiatric disorders. Magnetic Resonance Imaging (MRI) studies suggest that in addition to its functional impact, exposure to severe emotional trauma during childhood may cause alterations in the brain structure. In addition, early life stress has been related to changes in specific brain systems that have been implicated in adult psychopathology. 12 CU IDOL SELF LEARNING MATERIAL (SLM)

Preclinical studies have shown that childhood abuse and neglect promote long-term changes in stress reactivity and brain development. Approximately a decade ago, Sanchez and colleagues were the first to demonstrate that early stress, in the form of maternal separation, is associated with a reduced corpus callosum area in non-human primates. Reduced corpus callosum, hippocampus and temporal lobe regions were also observed in male bonnet macaques that were subjected to variable foraging demand (VFD) rearing. VFD is an early life stress paradigm in which infant bonnet macaques are reared by mothers undergoing an experimentally induced \"perception\" of food uncertainty. VFD and non-VFD mothers and infants differ on a number of behavioural and biological indices that persist throughout development, including disrupted maternal-infant attachment, increased stress reactivity, synchronized maternal-infant elevation of corticotrophin-releasing factor (CRF) concentrations in cerebrospinal fluid (CSF), and reduced neuronal integrity. Preclinical research has examined the long-term impact of early life stress in adult animals. These studies aid in the understanding of the pathophysiology of post-traumatic stress disorder (PTSD) in adults, as many of the biological alterations associated with early life stress are also reported in adults with PTSD and other stress-related disorders. The one MRI study that was conducted on pre-pubescent nonhuman primates that were subjected to early life stress demonstrated a reduction in the corpus callosum. However, the lack of studies makes the application of preclinical research findings to paediatric PTSD somewhat limited. Multiple independent MRI studies of maltreated children with PTSD have shown a reduction in the corpus callosum. A reduction in callosal fractional anisotropy, a measure of axonal integrity, has also recently been reported in maltreated children with PTSD. Unlike studies that evaluated children and adolescents with PTSD secondary to maltreatment and reported structural callosal abnormalities, studies involving adults with PTSD have consistently reported reductions in hippocampal volume. Only two studies evaluated the structure of the corpus callosum in adults with PTSD who were exposed to early life adversity, and they presented conflicting results. One study reported a reduced posterior callosum area. The second study, which was performed on a smaller scale, failed to replicate these findings. Emerging evidence suggests that the neurobiological effects of stress vary at different developmental stages. Differences in brain image findings in studies with adults and children may also be attributed to differences in brain maturation. It has been proposed that callosal abnormalities in children with PTSD are due to atrophy or neurodevelopmental deficits that result from traumatic experiences. There is preclinical evidence that very early life experiences can dramatically impact the morphometry of the corpus callosum. The myelination of the corpus callosum begins between the ages of 6 months and 3 years and continues into the third decade of life. In addition to the effects of stress and glucocorticoids on cell proliferation in the hippocampus, glucocorticoids have been shown to inhibit the proliferation of the oligodendrocyte precursor throughout the brain. Consistent with the role of oligodendrocyte precursors in myelination, prenatal glucocorticoid exposure has been 13 CU IDOL SELF LEARNING MATERIAL (SLM)

associated with reduced myelination of the corpus callosum and reduced myelin sheath thickness. The rostral-to-caudal myelination sequence suggests that different regions of the corpus callosum might have different windows of vulnerability to early experiences. Another possibility, however, is that abnormalities in corpus callosum morphology are due to developmental/genetic factors and predispose individuals to develop PTSD after exposure to trauma. Figure 1.1: Impact of the Association Between Trauma and Psychopathology Studies have also shown a possible association between exposure to trauma and the development of psychosis; 94% of patients with schizophrenia reported a childhood trauma. A history of trauma is also associated with persecutory ideation and hallucinations. This diagnosis is determined earlier in victims of childhood abuse and is associated with a larger number of previous hospitalizations, first hospitalization at an earlier age, anxiety symptoms, depression, and suicide. Dissociative symptoms and functional and social impairment in patients with schizophrenia spectrum disorders are related to childhood trauma. In a study by Goff et al., patients with psychotic disorders and a history of childhood trauma reported significantly more dissociative symptoms than patients without abuse experiences. Psychotic symptoms were more common in subjects exposed to a larger number of traumas and were associated with higher rates of childhood adversity, emotional and behavioural disturbance, and dysfunctional parenting. Exposure to multiple traumas, rather than a single major trauma, increases the risk of later psychosis. 1.5 TEMPERAMENT Specific temperament traits, defined as constitutionally based differences in emotional reactivity and self-regulation, have been found to predict behavioral (externalizing) problems and emotional (internalizing) problems in early childhood in several general population studies. Studies on links between temperament traits and internalizing and externalizing 14 CU IDOL SELF LEARNING MATERIAL (SLM)

problem behavior in young clinically referred children are scarce, however. We therefore do not know to what extent these associations are similar across general populations and clinically referred populations. Therefore, this study investigated temperament traits and their associations with internalizing and externalizing problem behavior in young clinically referred children and compared the strengths of these associations to an age and gender matched general population sample. Temperament is largely seen as the expression of heritable characteristics as these unfold through maturation and experience. Neural networks including the prefrontal and anterior cingulate cortices develop under influence of genetic and environmental factors and play an important role in emotional reactivity but also in emotion regulation, attention, and cognitive control. In young children, age three through seven, three broad temperament dimensions have been identified by Rothbart and colleagues: negative affectivity, extraversion/surgency and effortful control. The first two dimensions, negative affectivity and surgency, represent the tendency of children to react with either negative or positive emotions to daily situations. Children high in negative affectivity respond more readily with fear, sadness and/or anger and frustration in situations, while children with high surgency are inclined to express laughter, impulsivity, activity, and approach. The third dimension, effortful control (self- regulation), represents the ability to voluntarily regulate behavioural reactivity and attention, expressed by the inhibition of a dominant response and activation of a subdominant response. Several models have been proposed to explain the association between temperament and psychopathology. There is evidence for a spectrum model, which proposes that temperament traits and psychiatric disorders share etiological factors and vary along the same continuum with extreme levels of temperament traits considered psychopathology. There is also evidence for a vulnerability or resilience model, in which specific temperament traits predispose towards or protect against the onset of psychopathology in specific contexts. Furthermore, there are models in which temperament influences the expression of psychiatric symptoms (pathoplasty model), and vice versa, that psychopathology influences the expression of temperament (scar model). These last two theoretical models imply that associations between temperament traits and psychopathology could be different in clinically referred children with emotional and behavioural problems compared to non-referred children in the general population. 1.6 NEUROLOGY AND ETIOLOGY Borderline Personality Disorder (BPD) is one of many psychopathologies disorders a child can suffer from. In the neurobiological scheme, borderline personality disorder may have effects on the left amygdala. In a 2003 study of BPD patients versus control patients, when faced with expressions that were happy, sad, or fearful BPD patients showed significantly more activation versus control patients. In neutral faces, BPD patients attributed negative 15 CU IDOL SELF LEARNING MATERIAL (SLM)

qualities to these faces. As stated by Gabbard, an experimenter in this study: \"A hyperactive amygdala may be involved in the predisposition to be hyper vigilant and over reactive to relatively benign emotional expressions. Misreading neutral faces is clearly related to transference misreading’s that occur in psychotherapy and the creation of bad object experiences linked with projective identification.\" Also linked to BPD, is the presence of serotonin transporter (5-HTT) in a short allele demonstrated larger amygdala neuronal activity when presented with fearful stimuli as in comparison to individuals with a long allele of 5-HTT. As found in the Dunedin Longitudinal Study a short allele of 5-HTT predisposes the person to have hyperactivity in the amygdala in response to trauma, and thus moderated the impact of stressful life events leading to a higher risk of depression and suicidal idealities. These same qualities were not observed in individuals with long alleles of 5-HTT. However, the environment the child is in can change in impact of this gene, proving that correct treatment, intensive social support, and a healthy and nurturing environment can modify genetic vulnerability. Possibly the most studied or documented of the child psychopathologies is attention deficit hyperactivity disorder (ADHD) which is marked with learning disabilities, mood disorders, and/or aggression. Though believed to be over diagnosed, ADHD is highly comorbid for other disorders such as depression and obsessive compulsive disorder. In studies of the prefrontal cortex in ADHD children, which is responsible for the regulation of behavior, cognition, and attention; and in the dopamine system there has been identified a hidden genetic polymorphism. More specific, the 7-repeat allele of the dopamine D4 receptor gene, responsible for inhibited prefrontal cortex cognition and less efficient receptors, causes more externalized behaviours such as aggression since the child has trouble \"thinking through\" seemingly ordinary and at level childhood tasks. 1.7 AGENESIS OF CORPUS CALLOSUM AND ETIOLOGY Agenesis of corpus callosum (ACC) is a rare disorder that is present at birth (congenital). It is characterized by a partial or complete absence (agenesis) of an area of the brain that connects the two cerebral hemispheres. This part of the brain is normally composed of transverse fibres. The cause of agenesis of corpus callosum is usually not known, but it can be inherited as either an autosomal recessive trait or an X-linked dominant trait. It can also be caused by an infection or injury during the twelfth to the twenty-second week of pregnancy (intrauterine) leading to developmental disturbance of the foetal brain. Intrauterine exposure to alcohol (Foetal alcohol syndrome) can also result in ACC. In some cases mental retardation may result, but intelligence may be only mildly impaired and subtle psychosocial symptoms may be present. 16 CU IDOL SELF LEARNING MATERIAL (SLM)

ACC is frequently diagnosed during the first two years of life. An epileptic seizure can be the first symptom indicating that a child should be tested for a brain dysfunction. The disorder can also be without apparent symptoms in the mildest cases for many years. Agenesis of corpus callosum (ACC) may initially become evident through the onset of epileptic seizures during the first weeks of life or within the first two years. However, not all individuals with ACC have seizures. (For more information on these types of seizures choose “epilepsy” as your search term in the Rare Disease Database). Other symptoms that may begin early in life are feeding problems and delays in holding the head erect. Sitting, standing, and walking may also be delayed. Impairment of mental and physical development, and/or an accumulation of fluid in the skull (hydrocephalus) are also symptomatic of the early onset type of this disorder. (For more information, choose “hydrocephalus” as your search term in the Rare Disease Database.) Non-progressive mental retardation, impaired hand-eye coordination and visual or auditory (hearing) memory impairment can be diagnosed through neurological testing of patients with ACC. In some mild cases, symptoms may not appear for many years. Older patients are usually diagnosed during tests for symptoms such as seizures, monotonous or repetitive speech, or headaches. In mild cases it may be overlooked due to lack of obvious symptoms during childhood. Some patients may have deep-set eyes and a prominent forehead. An abnormally small head (microcephaly), or sometimes an unusually large head (macrocephaly), may be present. Tags of skin in front of the ears (pre-auricular skin tags), one or more bent fingers (camptodactyly), and delayed growth have also been associated with some cases of agenesis of corpus callosum. In other cases wide-set eyes (tele canthus), a small nose with upturned (ant everted) nostrils, abnormally shaped ears, excessive neck skin, short hands, diminished muscle tone (hypotonia), abnormalities of the larynx, heart defects, and symptoms of Pierre- Robin syndrome may be present. (For more information choose “Pierre-Robin” as your search term in the Rare Disease Database). Aicardi syndrome, thought to be inherited as an X-linked dominant disorder, consists of agenesis of corpus callosum, infantile spasms, and abnormal eye structure. This disorder is an extremely rare congenital disorder in which frequent seizures, striking abnormalities of the eye’s middle coat (choroid) and retinal layers, and the absence of the structure linking the two cerebral hemispheres (the corpus callosum), accompany severe mental retardation. Only females are affected. (For more information on this disorder, choose “Aicardi” as your search term in the Rare Disease Database). 17 CU IDOL SELF LEARNING MATERIAL (SLM)

Andermann syndrome, identified in 1972, is a genetic disorder characterized by a combination of agenesis of corpus callosum, mental retardation, and progressive sensorimotor nervous system disturbances (neuropathy). All known cases of this disorder originate from Charlevois County and the Saguenay-Lac St. Jean area of Quebec, Canada. The gene causing this rare form of ACC was recently identified and testing for this gene (SLC12A6) is currently available. XLAG (X linked lissencephaly with ambiguous genitalia is a rare genetic disorder in which males have small and smooth brains (lissencephaly), small penis, severe mental retardation, and intractable epilepsy. This is caused by mutations in the ARX gene. In females, these same mutations can cause ACC alone, whereas less severe mutations in males can cause mental retardation. Testing for this disorder is also clinically available. 1.8 TREATMENT Many child psychopathology disorders are treated with control medications prescribed by a paediatrician or psychiatrist. After extensive evaluation of the child through school visits, by psychologists and physicians, a medication can be prescribed. A patient may need to go through several trials of medicines to find the best fit, as many cause uncomfortable and undesired side effects- such as dry mouth or suicidal thoughts can occur. There are many classes of drugs a physician can choose from and they are: psychostimulants, beta blockers, atypical antipsychotics, lithium, alpha-2 agonists, traditional antipsychotics, SSRIs, and anticonvulsant mood- stabilizers. Given the multifocality of psychopathological disorders, two children may be on the same medication for two completely different disorders, or have the same disorder and be taking two completely different medications. ADHD is the most successfully treated disorder of child psychopathology, and the medications used have a high- abuse rate especially among college-aged students. Psycho stimulants such as Ritalin, amphetamine- related stimulant drugs: e.g., Adderall, and antidepressants such as Wellbutrin have been successfully used to treat ADHD with a 78% success rate. Many of these drug treatment options are paired with behavioral treatment such as therapy or social skills lessons. Lithium has shown to be extremely effective in treating ADHD and bipolar disorder. Lithium treats both mania and depression and helps prevent relapse. The mechanism of lithium include the inhibition of GSK-3, it is a glutamate antagonism at NMDA receptors that together make lithium a medicine. The drug relieves bipolar symptoms, aggressiveness, and irritability. Lithium has many, many side effects and requires weekly blood tests to tests for toxicity of the drug. Medications that act on cell membrane ion channels, are GABA inhibitory neurotransmission, and also inhibit excitatory glutamate transmission have shown to be 18 CU IDOL SELF LEARNING MATERIAL (SLM)

extremely effective in treating an array of child psychopathological disorders. Pharmaceutical companies are in the process of creating new drugs and improving those on the market to help avoid negative and possibly life altering short term and long term side effects, making drugs safer to use in younger children and over long periods of time during adolescent development. Some psychological disorders commonly found in children include depression, anxiety, and conduct disorder. For adolescents with depression, a combination of antidepressants and cognitive-behavioural or interpersonal psychotherapy is recommended, in contrast there is not much evidence for the efficacy of antidepressants in children under 12 years of age, therefore a combination of parent training and cognitive-behavioural psychotherapy is recommended. For children and adolescents suffering from anxiety disorders, cognitive- behavioural therapy in combination with exposure-based techniques is a highly recommended and evidence-based treatment.[22][23] Research suggests that children and adolescents with conduct disorder or disruptive behaviour may benefit from psychotherapy that includes both a behavioural component and parental involvement. 1.9 PSYCHOTHERAPY TREATMENTS FOR COMMON PSYCHOLOGICAL DISORDERS IN CHILDREN Psychotherapy, also known as “talk therapy,” is when a person speaks with a trained therapist in a safe and confidential environment to explore and understand feelings and behaviours and gain coping skills. During individual talk therapy sessions, the conversation is often led by the therapist and can touch on topics such as past or current problems, experiences, thoughts, feelings, or relationships experienced by the person while the therapist helps make connections and provide insight. Studies have found individual psychotherapy to be effective at improving symptoms in a wide array of mental illnesses, making it both a popular and versatile treatment. It can also be used for families, couples, or groups. Best practice for treating many mental health conditions includes a combination of medication and therapy. Popular Types of Psychotherapy Therapists offer many different types of psychotherapy. Some people respond better to one type of therapy than another, so a psychotherapist will take things like the nature of the problem being treated and the person’s personality into account when determining which treatment will be most effective. Cognitive Behavioural Therapy 19 CU IDOL SELF LEARNING MATERIAL (SLM)

Cognitive behavioural therapy (CBT) focuses on exploring relationships among a person's thoughts, feelings, and behaviours. During CBT a therapist will actively work with a person to uncover unhealthy patterns of thought and how they may be causing self-destructive behaviours and beliefs. By addressing these patterns, the person and therapist can work together to develop constructive ways of thinking that will produce healthier behaviours and beliefs. For instance, CBT can help someone replace thoughts that lead to low self-esteem (\"I can't do anything right\") with positive expectations (\"I can do this most of the time, based on my prior experiences\"). The core principles of CBT are identifying negative or false beliefs and testing or restructuring them. Oftentimes someone being treated with CBT will have homework in between sessions where they practice replacing negative thoughts with more realistic thoughts based on prior experiences or record their negative thoughts in a journal. Studies of CBT have shown it to be an effective treatment for a wide variety of mental illnesses, including depression, anxiety disorders, bipolar disorder, eating disorders and schizophrenia. Individuals who undergo CBT show changes in brain activity, suggesting that this therapy actually improves your brain functioning as well. Cognitive behavioural therapy has a considerable amount of scientific data supporting its use and many mental health care professionals have training in CBT, making it both effective and accessible. More are needed to meet the public health demand, however. 1.10 FUTURE OF CHILD PSYCHOPATHOLOGY The future of child psychopathology- etiology and treatment has a two-way path. While many professionals agree that many children who suffer from a disorder do not receive proper treatment, at the rate of 5-15% that receive treatment leaving many children in the dark. In the same boat are the physicians who also say that not only do more of these disorders need to be recognized in children and treated properly, but also even those children who show some qualifying symptoms of a disorder but not to the degree of diagnosis should also receive treatment and therapy to avoid the manifestation of the disorder. By treating children even with slight degrees of a psychopathological disorder, children can show improvements in their relationships with peers, family, and teachers and also improvements in school, mental health, and personal development. Many physicians believe the best prevention and help starts in the home and the school of the child, before physicians and psychologists are contacted. So while there is more awareness of child psychopathological disorders and more research to prevent and effectively treat these disorders to maintain healthy emotional health in children, there is also a negative factor in that parents, schools, and psychologists may be more 20 CU IDOL SELF LEARNING MATERIAL (SLM)

sensitive and therefore over-diagnose children with these disorders. Mental health professionals and pharmaceutical marketing companies need to be cautious of making disorders too readily diagnosed and treated with medications. Child psychopathology is a real thing that thousands of children suffer from. While hundreds of children are diagnosed with a new disorder daily, researchers are developing new strategies to beat these disorders in children to allow all children the right to a happy and healthy childhood. With further education on the symptoms and implications of child psychopathology, psychologists and physicians will improve their accuracy in diagnosing children- giving the right diagnosis and discovering the most helpful treatment and therapies for children. 1.11 THEORY AND RESEARCH The current trend in the U.S. is to understand child psychopathology from a systems based perspective called developmental psychopathology. Recent emphasis has also been on understanding psychological disorders from a relational perspective with attention also given to neurobiology. Practitioners who follow attachment theory believe that early attachment experiences of children can promote adaptive strategies or lay the groundwork for maladaptive ways of coping which can later lead to mental health disorders. Research and clinical work on child psychopathology tends to fall under several main areas: etiology, epidemiology, diagnosis, assessment, and treatment. Parents are considered a reliable source of information because they spend more time with children than any other adult. A child's psychopathology can be connected to parental behaviours. Clinicians and researchers have experienced problems with children's self-reports and rely on adults to provide the information. Understanding the etiology and structure of mental disorders is the purpose of psychopathology research, and an especially timely issue presently with recent revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), and initiatives such as the Research Domain Criteria (RDoC). Evidence from several different lines of work such as behavioral and molecular genetics, neuroimaging, family studies, etc. has been considered in both of these initiatives but transformative progress has been more difficult than anticipated (Kupfer & Regier, 2011). We contend what is particularly required is a framework and strategy for integrating the data from such diverse studies. Cronbach (1957) proposed that studies in psychology could be broadly divided into two streams – experimental and correlational. Such a strict division may not necessarily be the case in current times, and a range of studies exist that amalgamate these two streams of thought to differing degrees, such as quasi-experimental research (Rutter, 2007; Shadish, Cook, & Campbell, 2001). Indeed, this kind of paradigm – one that combines the causal significance of laboratory tests with the 21 CU IDOL SELF LEARNING MATERIAL (SLM)

import of studies involving people as they function in the real world – is much needed in psychopathology research and should be advocated on a much grander scale. The place to begin is with a guiding theory that informs how to evaluate evidence for or against a particular hypothesis. Theories may be derived from pre-existing notions of a particular disorder, or may arise out of the data after evaluating a certain amount of evidence for or against it (such as with exploratory data analysis; Tukey, 1980). The strategy we advocate here, however goes beyond that – here, we focus on the interface between research design, statistics, psychology, and neurobiology, and the extent of theoretical inference that can legitimately be drawn from them. Such an approach will require us to (a) move beyond an overreliance on advanced statistics and the use of new technology, especially in the absence of causally informative research design; and (b) integrate data in a meaningful way across methodologies using theoretically guided designs, and (c) test such theories using stringent study designs that allow us to make less ambiguous inferences regarding causality. In particular, the emphasis on the process of quantification and the use of advanced technology in some research occurs at the expense of theoretical or study design considerations, and lends an illusory quality of validity or deeper meaning to the results than warranted (Tavris, 2010) – a process that can easily lead to misguided conclusions and misallocation of research dollars. Stated more concisely, to advance our understanding of the etiology of mental disorder, we as a field must employ, whenever possible, risky tests of causal theories. What is a risky test? The risky test, in our view, is or approximates an experimental design and narrows the number of interpretive possibilities regarding causality, such that the riskier the test, the stronger the inference one can draw about the theory being tested. The ultimate risky test provides the opportunity to falsify and reject a theory, but we recognize this is seldom if ever possible in our field (Meehl, 1990), in part due to the inherent limitations of true experiments in psychology, especially when dealing with the ethical and legal obligations involved in research with human subjects (Meehl, 1978). In the absence of a true experiment, there are however, many clever ways to devise tests to be as risky as possible. Thus, we will use the phrase “risky test” to refer to (quasi-) experimental designs that not only allow strong inference about the tested theory, but are also practically feasible. If we perform risky tests from a variety of independent study designs then, when the results converge on the same interpretation, we have especially compelling evidence for theory corroboration or falsification. We turn now to a conceptual discussion about the utility of statistics in testing theories about psychopathology, the use of novel technology in understanding mental disorders, the relationship between these domains and, lastly, the possible inferences one can legitimately draw this research. Our point here is not to examine the philosophical bases underlying mental disorders or statistics, though we do occasionally cover such concerns as part of our 22 CU IDOL SELF LEARNING MATERIAL (SLM)

discussion. Nor do we focus solely on statistical issues such as replication, or multiple testing, or even questionable research practices (for an excellent discussion on these and related topics, see November 2012 issue of Perspectives on Psychological Science Pashler & Wagenmakers, 2012). Rather, the crux of our paper is focused on how to simultaneously leverage all our available research tools, use them to test etiological theory, and thereby arrive at the causal insights necessary to create, for example, a psychiatric nosology grounded in etiology, rather than one cantered on descriptive psychopathology. 1.12 SUMMARY • Psychopathology is a scientific discipline which has evolved over the years. It involves studying maladaptive behaviour, mental distress, and mental illness. • Psychopathology is concerned with studying disease elements which affect the mental state of people. Abnormal psychology is a discipline within psychology involving the study of unusual emotion, thought or behaviour patterns. • These unusual emotions thought or behaviour patterns may be due to mental disorders, in some cases. Throughout history, behaviour seen as deviant or aberrant has been studied and ways to control it sought. • Abnormal psychology uses diverse theories and different causalities for conditions to understand these forms of behaviour. Historically, the major debate has hinged on body-mind problem with many explanations focusing on the biological and psychological debates (Comer, 2006). • Biological model assumes that the neuroanatomy, bio-chemicals, and brain are physical in nature and that their role is to regulate psychological processes (Hansell & Damour, 2005). This in turn means that treatment of mental abnormalities should be biological and physical in nature. • Evidence to support this model stems from Serotonin, a neurotransmitter which has been linked with development of disorders such as anorexia nervosa and bipolar disorder. This model supports the use of drugs or surgery in treating abnormal behaviour, which is seen as a disease. Other treatment interventions in this model include electroconvulsive therapy and other therapeutic techniques. • Weaknesses of this model arising from use of drugs, is the possibility of causing addiction or allergic reaction to patients (Sims, 2002). • Psychosocial model analyses how individuals interact with the environment. According to Studer (2006), this model was developed by Erikson, a psychologist, as a means of explaining mental disorders. He gave eight factors which evaluated the mental development of a person. • These are independence, trust, industry, enterprise, intimacy, individuality, integrity, and productivity. He explained that for one to move to a different stage, the present 23 CU IDOL SELF LEARNING MATERIAL (SLM)

stage must be completed. In case one did not fully complete a stage or chose a disadvantageous stage, then he or she may develop a mental disorder. • This model is consistent with the diagnostic manual of mental illnesses (4th axis), which evaluate environmental factors which lead to mental disorders (American Psychiatric Association, 2000). These include schooling, social environment, lodging, work, health care and financial services, environmental and legal system. • Socio-cultural model evaluates cultural and social effects which are present in society. It emphasizes that behaviour is understood best according to cultural and social forces which influence individuals. These include social norms, family structures, social roles, social perception of individual and other aspects of society (Masterpasqua, 2009). • Two sociology fields, that is, study of social institutions and culture, and study of social groups and human relationships, guide the socio-cultural model. When behaviour is deemed to be significantly different from that expected by society, or that prevalent in society, then it is considered abnormal. 1.13 KEYWORDS • Personality: It refers to individual differences in characteristic patterns of thinking, feeling, and behaving. The study of personality focuses on two broad areas: One is understanding individual differences in particular personality characteristics, such as sociability or irritability • Child psychopathology: It refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood • Chronic diseases : These are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both • Psychiatric disorders: A wide range of conditions that affect mood, thinking and behaviour. • Borderline personality disorder: It is a mental health disorder that impacts the way you think and feel about yourself and others, causing problems functioning in everyday life. It includes self-image issues, difficulty managing emotions and behaviour, and a pattern of unstable relationships. 1.14 LEARNING ACTIVITY 1. Study current trend in the U.S. to understand child psychopathology ……………………………………………………………………………………………… ………………………………………………………………………………………………. 24 CU IDOL SELF LEARNING MATERIAL (SLM)

2. Discuss “talk therapy” in child psychopathology ……………………………………………………………………………………………… ………………………………………………………………………………………………. 1.15 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Who Works In Psychopathology? 2. What are causes of psychopathology? 3. Explain different types of psychopathology 4. What is influence of childhood stress on brain structures? 5. What is influence of childhood stress on cognitive performance? Long Questions 1. How to we identify Psychopathology. 2. Write a note on “Stress”. 3. What is “temperament”. 4. What is “Borderline Personality Disorder”. 5. What is “Agenesis of corpus callosum”. B. Multiple Choice Questions 1. The term “psychopathology” was first introduced by a. Carl Jung b. Sigmund Freud c. Karl Jasper d. Wilhelm Wundt 2. This term refers to thoughts, emotions or behavior that deviate from what is common or odds with what is deemed acceptable in the society. a. Distress b. Dysfunction c. Danger d. Deviance 3. Cause of psychopathology when you’re body’s defence take effect and create a stress response, which make you feel a variety of physical symptoms, behave differently and experience more intense emotion. 25 CU IDOL SELF LEARNING MATERIAL (SLM)

a. Substance of alcohol abuse b. Traumatic or stressful experiences c. Feelings of isolation d. None of these 4. _______________ techniques have been improving and becoming more accessible. Such techniques are valuable tools for unravelling the neurobiological underpinnings of psychiatric disorders. a. Neuroimaging b. Magnetic Resonance Imaging (MRI) c. Variable foraging demand d. Experimental-induced perception 5. A rare disorder that is present at birth (congenital). It is characterized by a partial or complete absence (agenesis) of an area of the brain that connects the two cerebral hemispheres. a. Trauma b. Dissociative symptoms c. Agenesis of corpus callosum d. Epileptic seizure Answers 1-(c), 2-(d), 3-(b), 4-(a), 5-(c) 1.16 REFERENCES Textbooks • Halonen J (2005) Abnormal psychology as liberating art and science. J Soc Clin Psychol • Hinshaw S, Cicchetti D (2000) Stigma and mental disorder: conceptions of illness, public attitudes, personal disclosure, and social policy. Dev Psychopathology • Keane M (1991) Acceptance vs. rejection: nursing students’ attitudes about mental illness. Perspect psychiatric Care • Kolodziej M, Johnson B (1996) Interpersonal contact and acceptance of persons with psychiatric disorders: a research synthesis. J Cons Clin Psychol • Link B, Cullen F, Frank J et al (1987) The social rejection of former mental patients: understanding why labels matter. Am J Soc Reference Books 26 CU IDOL SELF LEARNING MATERIAL (SLM)

• Link B, Struening E, Neese-Todd S et al (2001) Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illness. Psychiatry Serv • Llerena A, Caceres M, Penas-Lledo E (2002) Schizophrenia stigma among medical and nursing undergraduates. Eur Psychiatry • Mann C, Himelein M (2004) Factors associated with the stigmatization of persons with mental illness. Psychiatry Survey • Chrisler J (1992) Exploring mental illness through a poetry writing assignment. Teach Psycho • Chou K, Mak K (1998) Attitudes to mental patients among Hong Kong Chinese: a trend study over two years. Int J Soc Psychiatry 27 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 2: NATURE OF CHILD PSYCHOPATHOLOGY STRUCTURE 2.0 Learning Objectives 2.1 Introduction 2.2 Nature of Child Psychopathology 2.3 Causes of Child Psychopathology 2.4 Biological, Psychological, Family and Social Influences 2.5 Summary 2.6 Keywords 2.7 Learning Activity 2.8 Unit End Questions 2.9 References 2.0 LEARNING OBJECTIVES After studying this unit, student will be able to: • Explain the nature of child psychopathology • Explain the causes of child psychopathology • State its biological, psychological, family, and social influences 2.1 INTRODUCTION The current field of study for childhood mental disorders is often referred to as child psychopathology, which involves the study of psychological and behavioural disorders in children and adolescents. In order to be considered as meeting the definition of a mental disorder, there must be a pattern of symptoms that leads to some level of distress, disability or interference with daily functioning, and an increase in risk for pain, suffering, or loss of freedom (e.g., institutionalization). In addition, the symptoms are not consistent with the norms of the culture, though they may appear to be exaggerations of normal behaviour or can occur in adaptation to some unusual circumstance (e.g., chronic illness, maltreatment). The Diagnostic and Statistical Manual of Mental Disorders (DSM) was originally developed as a taxonomy to categorize these patterns of behaviours into distinct mental disorders. Currently, the DSM is in its fourth edition (DSM-IV) and a fifth edition is expected to be 28 CU IDOL SELF LEARNING MATERIAL (SLM)

released in 2013. The DSM-IV lists numerous disorders as ‘usually first diagnosed in infancy, childhood, or adolescence,’ and these disorders will be discussed in the current article. Mood disorders and anxiety disorders are also common in children and adolescents, though in some instances they may not be diagnosed until adulthood. This review will focus on childhood mental disorders that are commonly seen in clinic populations, including the mood and anxiety disorders, attention-deficit and disruptive behaviour disorders, and pervasive developmental disorders (PDDs). Recent estimates suggest that 10–20% of youth meet criteria for a specific psychological disorder. Unfortunately, the majority of children with mental health problems do not receive services. About 20% of children with mental health problems will have significant difficulty throughout their lives, suggesting that childhood psychological disorders are long-lasting and continue into adulthood. 2.2 NATURE OF CHILD PSYCHOPATHOLOGY Child psychopathology is the manifestation of psychological disorders in childhood and adolescence; examples include Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Pervasive Developmental Disorders (Mash & Barkley, 2003). Factors Complicating the Study of Child Psychopathology Since modern views of mental illness began to emerge in the late 18th and early 19th centuries, there has been far less attention given to the study of child psychopathology than psychopathology in adults. An example of this is in 1812, when Benjamin Rush, the first American psychiatrist, suggested that children were less likely to suffer from mental illness because the immaturity of their developing brains would prevent them from retaining the mental events that caused insanity (Mash & Barkley, 2003). Fortunately, psychiatrists do not think this way. Recently interest in child psychopathology has increased. This is due to the growing realization that many childhood problems have lifelong consequences and costs both for children and for society, that most adult disorders are rooted in early childhood conditions and/or experiences, and that a better understanding of childhood disorders offers promise for developing effective intervention and prevention programs (Mash & Barkley, 2003). Another factor is that there are issues present concerning the conceptualization and definition of psychopathology in children continue to be debated. Also, there is the fact that in studies conducted with children, much of the knowledge gained is based on findings obtained at a single point in a child’s development and in a single context. A further complication is that childhood problems “do not come in neat packages” and that most forms of psychopathology in children are known to overlap and/or coexist with other disorders (Mash & Barkley, 2003, p. 4). As you come to learn about child psychopathology, you will see how much overlap really does occur and why this is such a complication. There is also a problem that distinct boundaries between many commonly occurring childhood difficulties and those problems 29 CU IDOL SELF LEARNING MATERIAL (SLM)

that become labelled as disorders are not easily drawn. There is also a growing recognition that all current diagnostic categories of child psychopathology are heterogeneous with respect to etiology and outcome, and will need to be broken down into subtypes, as you will see with the disorders mentioned on this page. It has also become increasingly evident that most forms of child psychopathology cannot be attributed to a single unitary cause. Some disorders cannot be linked to a single gene or a single event in life. There is also the complication that numerous determinants of child psychopathology have been identified, including genetic influences, hypo- or hyper-reactive early infant dispositions, insecure child-parent attachments, difficult child behaviour, social-cognitive deficits, deficits in social learning, emotion regulation, and/or impulse control and response inhibition (Mash & Barkley, 2003). The many causes and outcomes of child psychopathology operate in dynamic and interactive ways over time which makes it hard to disentangle them. To designate a specific favour as a cause or an outcome of child psychopathology usually reflects the point in an ongoing developmental process at which the child is observed and the perspective of the observer (Mash & Barkley, 2003). Significance of Child Psychopathology There has been and continues to be a great deal of misinformation and folklore concerning disorders of childhood (Mash & Barkley, 2003). Many of these unsubstantiated theories have existed in both the popular and scientific literature, one example is the misconception that over-stimulation in the classroom causes insanity. Many of the constructs used to describe the characteristics and conditions of psychopathology in children have been globally and/or poorly defined (Mash & Barkley, 2003). The growing attention to children’s mental health problems and competencies arises from a number of sources. First, many young people experience significant mental health problems that interfere with normal development and functioning. In fact, as many as 1 in 5 children in the United States experiences some type of difficulty and 1 in 10 have a diagnosable disorder that causes some level of impairment (Mash & Barkley, 2003). Second, a significant proportion of children do not grow out of their childhood difficulties, although the ways in which these difficulties are expressed change in both form and severity over time. Third, recent social changes and conditions may place children at increasing risk for the development of disorders and also for the development of more severe problems at younger ages. Fourth, for a majority of children who experience mental health problems, these problems go unidentified. Only about 20% receive help, a statistic that has not changed for some time (Mash & Barkley, 2003). Fifth, a majority of children with mental health problems who go unidentified and unassisted often end up in the criminal justice or mental health system as young adults. They are at greater risk of dropping out of school and of not being fully functional members of society. Finally, a significant number of children in North America are being subjected to maltreatment and chronic maltreatment during childhood that 30 CU IDOL SELF LEARNING MATERIAL (SLM)

is associated with psychopathology in children and later in adults. It has been estimated that each year as many as 2,000 infants and young children die from abuse or neglect at the hands of their parents or caregivers (Mash & Barkley, 2003). Epidemiological Considerations Prevalence The overall lifetime prevalence rates for childhood problems are estimated to be high and on the order of 14-22% of all children (Mash & Barkley, 2003). Rutter, Tizard, and Whitmore (1970) found in the classic Isle of Wight Study that the overall rate of child psychiatric disorders to be 6-8% in 9 to 11-year-old children (as cited in Mash & Barkley, 2003). Richman, Stevenson, and Graham (1975) found in the London Epidemiological Study that moderate to severe behaviour problems for 7% of the population with an additional 15% of children having mild problems (as cited in Mash & Barkley, 2003). Boyle et al. (1987) and Offord et al. (1987) reported in the Ontario Child Health Study that 19% of boys and 17% of girls had one or more disorders (as cited in Mash & Barkley, 2003). Many other epidemiological studies have reported similar rates of prevalence. Age Differences Some studies of nonclinical samples of children have found a general decline in overall problems with age, whereas similar studies of clinical samples have found an opposite trend. These and many other findings raise numerous questions concerning age differences in children’s problem behaviours. Answers to even a seemingly simple question such as “Do problem behaviours decrease (or increase) with age?” are complicated by a lack of uniform measures of behaviour that can be used across a wide range of ages, qualitative changes in the expression of behaviour with development, the interactions between age and sex of the child, the use of different informants, the specific problem behaviours of interest, the clinical status of the children being assessed, and the use of different diagnostic criteria for children of different ages (Mash & Barkley, 2003). Socioeconomic Status Although most children with mental health problems are from the middle class, mental health problems are overrepresented among the very poor. It is estimated that 20% or more of children in North America are poor, and that as many as 20% of children growing up in inner-city poverty are impaired to some degree in their social, behavioural, and academic functioning (Mash & Barkley, 2003). Sex Differences Findings relating to sex differences and child psychopathology are complex, inconsistent, and frequently difficult to interpret, the cumulative findings from research strongly indicate that 31 CU IDOL SELF LEARNING MATERIAL (SLM)

the effects of gender are critical to understanding the expression and course of most forms of childhood disorder (Mash & Barkley, 2003). Key Concepts of Child Psychopathology Several recurrent and overlapping issues have characterized the study of psychopathology in children (Cicchetti & Toth, 2009; Rutter & Sroufe, 2000). A number of these are highlighted in this section, including (1) difficulties in conceptualizing psychopathology and normality; (2) the need to consider healthy functioning and adjustment; (3) questions concerning developmental continuities and discontinuities; (4) the concept of developmental pathways; (5) the notions of risk and resilience; (6) the identification of protective and vulnerability factors; and (7) the role of contextual influences. Psychopathology Versus Normality The attempt to establish boundaries between what constitutes abnormal and normal functioning is an arbitrary process at best (see Achenbach, 1997), although this does not necessarily imply that such boundaries are meaningless if they are informative with respect to impairment and other clinically significant factors. Traditional approaches to mental disorders in children have emphasized concepts such as symptoms, diagnosis, illness, and treatment; by doing so, they have strongly influenced the way we think about child psychopathology and related questions (Richters & Cicchetti, 1993). Childhood disorders have most commonly been conceptualized in terms of deviancies involving breakdowns in adaptive functioning, statistical deviation, unexpected distress, or disability, and/or biological impairment. Wakefield (1992, 1997, 1999b, 2010) has proposed an overarching concept of mental disorder as “harmful dysfunction.” This concept encompasses a child’s physical and mental functioning, and includes both value- and science-based criteria. In the context of child psychopathology, a child’s condition is viewed as a disorder only if (1) it causes harm or deprivation of benefit to the child, as judged by social norms; and (2) it results from the failure of some internal mechanism to perform its natural function (e.g., “an effect that is part of the evolutionary explanation of the existence and structure of the mechanism”; Wakefield, 1992, p. 384). This view of mental disorder focuses attention on evolved adaptations or internal functional mechanisms—for example, executive functions in the context of self- regulation (Barkley, 2001). Nevertheless, as Richters and Cicchetti (1993) have pointed out, this view only identifies the decisions that need to be made in defining mental disorders; it does not specify how such decisions are to be made. As is the case for most definitions of mental disorder that have been proposed, questions related to defining the boundaries between normal and abnormal, understanding the differences between normal variability and dysfunction, defining what constitute “harmful conditions,” linking dysfunctions causally with these conditions, and circumscribing the domain of “natural” or of other proposed mechanisms are matters of considerable controversy (Hudziak, Achenbach, Althoff, & Pine, 2007; Lilienfeld & Marino, 1995).3 Categories of mental disorder stem from human-made 32 CU IDOL SELF LEARNING MATERIAL (SLM)

linguistic distinctions and abstractions, and boundaries between what constitutes normal and abnormal conditions, or between different abnormal conditions, are not easily drawn. Although it may sometimes appear that efforts to categorize mental disorders are “carving nature at its joints,” whether or not such “joints” actually exist is open to debate (e.g., Angold & Costello, 2009; Cantor, Smith, French, & Mezzich, 1980; Lilienfeld & Marino, 1995). However, clear distinctions do not necessarily need to exist for categorical distinctions to have utility. For instance, there is no joint at which one can carve day from night, although distinguishing the two has proven incredibly useful to humans in going about their social discourse and engagements. Likewise, although the threshold for determining disorder from high levels of symptoms may be fuzzy, it could be stipulated as being at that point along a dimension where impairment in a major, culturally universal life activity befalls the majority of people at or exceeding that point. Thus, despite the lack of clear boundaries between what is normal and abnormal, categorical distinctions are still useful as long as they adequately predict which children will be most likely to benefit from access to special education, treatment, or disability status. Children’s Mental Health Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities. Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day. Many children occasionally experience fears and worries or display disruptive behaviours. If symptoms are serious and persistent and interfere with school, home, or play activities, the child may be diagnosed with a mental disorder. Mental health is not simply the absence of a mental disorder. Children who don’t have a mental disorder might differ in how well they are doing, and children who have the same diagnosed mental disorder might differ in their strengths and weaknesses in how they are developing and coping, and in their quality of life. Mental health as a continuum and the identification of specific mental disorders are both ways to understand how well children are doing. 2.3 CAUSES OF CHILD PSYCHOPATHOLOGY There are a great diversity of childhood disorder forms and causes. Some of these disorders are primarily disorders of the brain, while others are more behavioural in nature. Brain-based disorders are caused by neurochemical problems or structural abnormalities of the brain. They can be innate (i.e., appearing at or shortly after birth); or they may result from a 33 CU IDOL SELF LEARNING MATERIAL (SLM)

physical stress such as illness or injury, or an emotional stress, such as trauma or loss. Behavioural problems, on the other hand, are outward signs of difficulty displayed at home, at school, or among friends in an otherwise physically healthy child. Like brain-based problems, behavioural problems may also result from physical or emotional stress. Note that the division between brain-based and behavioural disorders is somewhat arbitrary in many cases. Brain-based disorders such as ADHD clearly impact a child's behaviour in school and at home, and vice versa, many disorders previously thought to be primarily behavioural in nature have turned out to have a biological component to them. Some of the childhood disorders can be cured or otherwise resolved, while others end up becoming chronic (long-term) problems that resist the best state-of-the-art interventions. The disorders we will discuss also vary in terms of prevalence and severity. Prevalence refers to a ratio, or percentage, of how often a disease or disorder occurs within a group of people in a population at a given time. Recently, the American Psychological Association has noted an increase in the prevalence of childhood mental illnesses as a whole. Estimates of the current prevalence suggest that between 17.6% and 22% of children have symptoms of one or more childhood disorders; and that 15% of American children suffer from a mental illness that is severe enough to cause some level of functional impairment. Despite how common they may be, childhood disorders are not part of the normal developmental process that children are expected to go through. The diagnostic criteria for childhood mental disorders requires that children's behaviour and/or development deviates from normal age-appropriate behaviour and/or development, so understanding normal child development is important. For this reason, you might want to read over our extensive material concerning normal childhood development. Understanding normal developmental milestones for different ages puts you in a better position to understand why disordered behaviour is considered abnormal. Common Childhood Mental Disorders Among the more common mental disorders that can be diagnosed in childhood are attention- deficit/hyperactivity disorder (ADHD), anxiety (fears or worries), and behaviour disorders. Anxiety When a child does not outgrow the fears and worries that are typical in young children, or when there are so many fears and worries that they interfere with school, home, or play activities, the child may be diagnosed with an anxiety disorder. Examples of different types of anxiety disorders include • Being very afraid when away from parents (separation anxiety) • Having extreme fear about a specific thing or situation, such as dogs, insects, or going to the doctor (phobias) 34 CU IDOL SELF LEARNING MATERIAL (SLM)

• Being very afraid of school and other places where there are people (social anxiety) • Being very worried about the future and about bad things happening (general anxiety) • Having repeated episodes of sudden, unexpected, intense fear that come with symptoms like heart pounding, having trouble breathing, or feeling dizzy, shaky, or sweaty (panic disorder) Anxiety may present as fear or worry, but can also make children irritable and angry. Anxiety symptoms can also include trouble sleeping, as well as physical symptoms like fatigue, headaches, or stomach-aches. Some anxious children keep their worries to themselves and, thus, the symptoms can be missed. Depression Occasionally being sad or feeling hopeless is a part of every child’s life. However, some children feel sad or uninterested in things that they used to enjoy, or feel helpless or hopeless in situations they are able to change. When children feel persistent sadness and hopelessness, they may be diagnosed with depression. Examples of behaviours often seen in children with depression include • Feeling sad, hopeless, or irritable a lot of the time • Not wanting to do or enjoy doing fun things • Showing changes in eating patterns – eating a lot more or a lot less than usual • Showing changes in sleep patterns – sleeping a lot more or a lot less than normal • Showing changes in energy – being tired and sluggish or tense and restless a lot of the time • Having a hard time paying attention • Feeling worthless, useless, or guilty • Showing self-injury and self-destructive behaviour Extreme depression can lead a child to think about suicide or plan for suicide. For youth ages 10-24 years, suicide is among the leading causes of death. Some children may not talk about their helpless and hopeless thoughts, and may not appear sad. Depression might also cause a child to make trouble or act unmotivated, causing others not to notice that the child is depressed or to incorrectly label the child as a troublemaker or lazy. Treatment for Anxiety and Depression The first step to treatment is to talk with a healthcare provider such as your child’s primary care provider, or a mental health specialist, about getting an evaluation. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that healthcare providers routinely screen children for behavioural and mental health concerns. Some of the signs and symptoms of anxiety or depression in children could be caused by other conditions, 35 CU IDOL SELF LEARNING MATERIAL (SLM)

such as trauma. Specific symptoms like having a hard time focusing could be a sign of attention-deficit/hyperactivity disorder (ADHD). It is important to get a careful evaluation to get the best diagnosis and treatment. Consultation with a health provider can help determine if medication should be part of the treatment. A mental health professional can develop a therapy plan that works best for the child and family. Behaviour therapy includes child therapy, family therapy, or a combination of both. The school can also be included in the treatment plan. For very young children, involving parents in treatment is key. Cognitive- behavioural therapy is one form of therapy that is used to treat anxiety or depression, particularly in older children. It helps the child change negative thoughts into more positive, effective ways of thinking, leading to more effective behaviour. Behaviour therapy for anxiety may involve helping children cope with and manage anxiety symptoms while gradually exposing them to their fears so as to help them learn that bad things do not occur. Treatments can also include a variety of ways to help the child feel less stressed and be healthier like nutritious food, physical activity, sufficient sleep, predictable routines, and social support. Behaviour or Conduct Problems in Children Children sometimes argue, are aggressive, or act angry or defiant around adults. A behaviour disorder may be diagnosed when these disruptive behaviours are uncommon for the child’s age at the time, persist over time, or are severe. Because disruptive behaviour disorders involve acting out and showing unwanted behaviour towards others they are sometimes called externalizing disorders. Oppositional Defiant Disorder When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviours more often than other children their age. Examples of ODD behaviours include • Often being angry or losing one’s temper • Often arguing with adults or refusing to comply with adults’ rules or requests • Often resentful or spiteful • Deliberately annoying others or becoming annoyed with others • Often blaming other people for one’s own mistakes or misbehaviour Conduct Disorder 36 CU IDOL SELF LEARNING MATERIAL (SLM)

Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers. Examples of CD behaviours include • Breaking serious rules, such as running away, staying out at night when told not to, or skipping school • Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals • Lying, stealing, or damaging other people’s property on purpose Treatment for Disruptive Behaviour Disorders Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behaviour problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behaviour therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behaviour. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school. Obsessive-Compulsive Disorder in Children Many children occasionally have thoughts that bother them, and they might feel like they have to do something about those thoughts, even if their actions don’t actually make sense. For example, they might worry about having bad luck if they don’t wear a favourite piece of clothing. For some children, the thoughts, and the urges to perform certain actions persist, even if they try to ignore them or make them go away. Children may have an obsessive- compulsive disorder (OCD) when unwanted thoughts, and the behaviours they feel they must do because of the thoughts, happen frequently, take up a lot of time (more than an hour a day), interfere with their activities, or make them very upset. The thoughts are called obsessions. The behaviours are called compulsions. Symptoms Having OCD means having obsessions, compulsions, or both. Examples of obsessive or compulsive behaviours include: 37 CU IDOL SELF LEARNING MATERIAL (SLM)

• Having unwanted thoughts, impulses, or images that occur over and over and which cause anxiety or distress. • Having to think about or say something over and over (for example, counting, or repeating words over and over silently or out loud) • Having to do something over and over (for example, handwashing, placing things in a specific order, or checking the same things over and over, like whether a door is locked) • Having to do something over and over according to certain rules that must be followed exactly in order to make an obsession go away. Children do these behaviours because they have the feeling that the behaviours will prevent bad things from happening or will make them feel better. However, the behaviour is not typically connected to actual danger of something bad happening, or the behaviour is extreme, such as washing hands multiple times per hour. A common myth is that OCD means being really neat and orderly. Sometimes, OCD behaviours may involve cleaning, but many times someone with OCD is too focused on one thing that must be done over and over, rather than on being organized. Obsessions and compulsions can also change over time. Post-traumatic Stress Disorder in Children All children may experience very stressful events that affect how they think and feel. Most of the time, children recover quickly and well. However, sometimes children who experience severe stress, such as from an injury, from the death or threatened death of a close family member or friend, or from violence, will be affected long-term. The child could experience this trauma directly or could witness it happening to someone else. When children develop long term symptoms (longer than one month) from such stress, which are upsetting or interfere with their relationships and activities, they may be diagnosed with post-traumatic stress disorder (PTSD). Examples of PTSD symptoms include • Reliving the event over and over in thought or in play 38 • Nightmares and sleep problems • Becoming very upset when something causes memories of the event • Lack of positive emotions • Intense ongoing fear or sadness • Irritability and angry outbursts • Constantly looking for possible threats, being easily startled • Acting helpless, hopeless, or withdrawn CU IDOL SELF LEARNING MATERIAL (SLM)

• Denying that the event happened or feeling numb • Avoiding places or people associated with the event Because children who have experienced traumatic stress may seem restless, fidgety, or have trouble paying attention and staying organized, the symptoms of traumatic stress can be confused with symptoms of attention-deficit/hyperactivity disorder (ADHD). Examples of events that could cause PTSD include • Physical, sexual, or emotional maltreatment • Being a victim or witness to violence or crime • Serious illness or death of a close family member or friend • Natural or manmade disasters • Severe car accidents Treatment for PTSD The first step to treatment is to talk with a healthcare provider to arrange an evaluation. For a PTSD diagnosis, a specific event must have triggered the symptoms. Because the event was distressing, children may not want to talk about the event, so a health provider who is highly skilled in talking with children and families may be needed. Once the diagnosis is made, the first step is to make the child feel safe by getting support from parents, friends, and school, and by minimizing the chance of another traumatic event to the extent possible. Psychotherapy in which the child can speak, draw, play, or write about the stressful event can be done with the child, the family, or a group. Behaviour therapy, specifically cognitive- behavioural therapy, helps children learn to change thoughts and feelings by first changing behaviour in order to reduce the fear or worry. Medication may also be used to decrease symptoms. Therapy to Improve Children’s Mental Health Mental, emotional, and behavioural disorders in childhood can cause long-term problems that may affect the health and well-being of children, families, and communities. Treating a child’s mental health problems as soon as possible can help children reduce problems at home, in school, and in forming friendships. It can also help with healthy development into adulthood. A public health approach to children’s mental health includes promoting mental health for all children, providing preventive intervention to children at risk, and providing treatment for children with identified disorders. Psychological therapy is a key component to improving mental health. Depending on the type and severity of the problems, psychological therapy for children may be used in combination with medication.1 For the most common childhood conditions, like ADHD, behaviour disorders, anxiety, or depression, approaches using behaviour therapy and cognitive-behaviour therapy are more 39 CU IDOL SELF LEARNING MATERIAL (SLM)

likely to reduce symptoms, but there is limited information about which type of therapy is best for treating each specific childhood mental disorder. Based on the scientific evidence available, different therapies seem to work well for different types of problems: Parent training in behaviour management works well for • ADHD; and • Disruptive behaviour disorders. Child behaviour therapy works well for • ADHD; and • Disruptive behaviour disorders. Cognitive-behaviour therapy works well for • Disruptive behaviour disorder. • Depression. • Anxiety; and • PTSD. Additional types of therapy can be effective for adolescents. • Adolescents with disruptive behaviour disorder may respond well to family therapy, an approach that includes multiple members of the family and focuses on learning better communication skills and ways to settle conflicts. • Adolescents with depression may respond well to interpersonal psychotherapy, an approach in which the therapists help the adolescents learn ways to handle relationship problems. Other therapy approaches may also be effective but have not been studied enough for researchers to understand if they work well. Information on what works best for which family is also still limited. Behaviour Therapy Behaviour therapy teaches children and their families how to strengthen positive child behaviours and eliminate or reduce unwanted or problem behaviours. One type is parent training in behaviour management. The therapist works with parents to learn or improve skills to manage their child’s behaviour. Parents are encouraged to practice the skills with their child, either during the therapy session or at home. Teachers can also be trained in behaviour management to help the child at their childcare centre or school. 40 CU IDOL SELF LEARNING MATERIAL (SLM)

With older children or adolescents, the therapist usually works directly with the child to teach them how to choose positive behaviours. Parents can be involved to support and strengthen the skills their child is learning. Cognitive-Behaviour Therapy Cognitive-behaviour therapy focuses on changing the thoughts and emotions that can affect a child’s behaviour negatively. The therapist helps the child become aware of their thoughts and feelings. The therapist also helps the child evaluate if feelings or thoughts may be distorted or illogical, and then helps the child through the process of changing the thoughts as well as the emotional reactions and behaviours that go along with them. Cognitive-behaviour therapy often works directly with the child, but can also include parents. 2.4 BIOLOGICAL, PSYCHOLOGICAL, FAMILY AND SOCIAL INFLUENCES Biological Factors Are Involved in Mental Illness The role and effect of biological, behavioural, and environmental influences change as children grow. For example, a pharmacological agent like thalidomide is highly toxic within a narrow window during pregnancy but not afterward, an attachment to a caring adult is especially critical during infancy, and peer influences appear to grow steadily from toddlerhood through adolescence. Even within a childhood stage, health influences can act in very different ways because of the differing cultural interpretations that families attach to them. While biology, behaviour, and environmental categories are useful for organizing our discussion, it is important to understand that healthy development is not the product of single, isolated influences or even types of influences. Warm and nurturing parenting is an important family influence, but prematurity or visual impairment can make an infant unresponsive to a mother’s initial nurturing. Mothers may react with apathy or disinterest, which produces even more withdrawal on the part of the infant. While simplified schematics or models help to organize understanding of the influences on children’s health both during childhood and beyond, life is not as simple as these models suggest. One caveat should be kept in mind in reading through the following review of evidence. Few of the cited studies drew their evidence from randomized experiments. And few if any of the non-experimental studies included all relevant variables in their data and analyses. Thus, the findings reported in these studies are likely to suffer from exclusion of potentially important categories of influences, so that the associations that are reported as being important may be 41 CU IDOL SELF LEARNING MATERIAL (SLM)

due to their associations with a more important or equally important characteristic, or due to interactions with other types of factors so that their effect may be manifested primarily or only in certain population groups. A related problem is that few of the cited studies include data that represent the whole population of children. Thus, the findings that are reported as significant may be significant only in the population studied or similar populations. Nonetheless, the committee found the evidence to be sufficiently compelling to warrant inclusion when there was a plausible, well-supported connection between the influence and health. Moreover, inferences about the relative importance of the variety of influences are heavily dependent on the nature of the theoretical models that underlie statistical analysis. If more proximal influences are mixed with more distal ones, they may appear to have stronger effects, even in situations in which more distal factors are operating on a multiplicity of proximal influences and therefore have cumulatively greater effect overall. Thus, future research should adapt more appropriate pathway techniques to help to sort out the patterns by which the influences interact to produce different states of health. Some mental illnesses have been linked to abnormal functioning of nerve cell circuits or pathways that connect particular brain regions. Nerve cells within these brain circuits communicate through chemicals called neurotransmitters. \"Tweaking\" these chemicals -- through medicines, psychotherapy, or other medical procedures -- can help brain circuits run more efficiently. In addition, defects in or injury to certain areas of the brain have also been linked to some mental conditions. Other biological factors that may be involved in the development of mental illness include: 1. Genetics (heredity): Mental illnesses sometimes run-in families, suggesting that people who have a family member with a mental illness may be somewhat more likely to develop one themselves. Susceptibility is passed on in families through genes. Experts believe many mental illnesses are linked to abnormalities in many genes rather than just one or a few and that how these genes interact with the environment is unique for every person (even identical twins). That is why a person inherits a susceptibility to a mental illness and doesn't necessarily develop the illness. Mental illness itself occurs from the interaction of multiple genes and other factors -- such as stress, abuse, or a traumatic event -- which can influence, or trigger, an illness in a person who has an inherited susceptibility to it. Major mental disorders traditionally thought to be distinct share certain genetic glitches, according to a new study. The finding may point to better ways to diagnose and treat these conditions. 42 CU IDOL SELF LEARNING MATERIAL (SLM)

Scientists have long recognized that many psychiatric disorders tend to run in families, suggesting potential genetic roots. Such disorders include autism, attention deficit hyperactivity disorder (ADHD), bipolar disorder, major depression, and schizophrenia. Symptoms can overlap and so distinguishing among these 5 major psychiatric syndromes can be difficult. Their shared symptoms suggest they may also share similarities at the biological level. In fact, recent studies have turned up limited evidence of shared genetic risk factors, such as for schizophrenia and bipolar disorder, autism and schizophrenia, and depression and bipolar disorder. To take a broader look, an international research consortium conducted an analysis that incorporated data from genome-wide association studies (GWAS) of the 5 major disorders. This type of study involves scanning through thousands of genetic markers in search of tiny variations that appear more often in people who have a particular condition than in those who don't. The research received primary funding from NIH’s National Institute of Mental Health (NIMH), along with other NIH components. As reported online in the Lancet on February 28, 2013, the scientists screened for evidence of illness-associated genetic variation among over 33,000 patients. All had been diagnosed with at least 1 of the 5 disorders. A comparison group included about 28,000 people who had no major psychiatric diagnosis. The analysis revealed variations significantly associated with all 5 disorders. These included variations in 2 genes that code for the cellular machinery that helps regulate the flow of calcium into neurons. Variation in one of these, called CACNA1C, had previously been linked to bipolar disorder, schizophrenia, and major depression. CACNA1C is known to affect brain circuitry involved in emotion, thinking, attention and memory — functions that can be disrupted in mental illnesses. Variation in another calcium channel gene, called CACNB2, was also linked to the 5 disorders. In addition, the researchers discovered illness-linked variation for all 5 disorders in certain regions of chromosomes 3 and 10. Each of these sites spans several genes, and causal factors haven’t yet been pinpointed. The suspect region along chromosome 3 had the strongest links to the disorders. This region also harbours certain variations previously linked to bipolar disorder and schizophrenia. “Although statistically significant, each of these genetic associations individually can account for only a small amount of risk for mental illness,” says study co-author Dr. Jordan Smoller of Massachusetts General Hospital. Because of this, the variations couldn’t yet be used to predict or diagnose specific conditions. But these results may help researchers move closer to making more accurate diagnoses. They may also help lead to a better understanding of the factors that cause these major mental disorders. 2. Infections: 43 CU IDOL SELF LEARNING MATERIAL (SLM)

Certain infections have been linked to brain damage and the development of mental illness or the worsening of its symptoms. For example, a condition known as paediatric autoimmune neuropsychiatric disorder (PANDAS) associated with the Streptococcus bacteria has been linked to the development of obsessive-compulsive disorder and other mental illnesses in children. Acute neurological syndromes caused by viruses Involvement of the brain is one of the most serious consequences of a viral infection. Many virus families have the ability to invade and replicate in brain tissue, but fortunately serious brain infections are rare. Clinically, neurological diseases caused by viruses can be divided into acute and chronic syndromes. The pathology may be due either to multiplication of virus in the cells of the brain or, due to the (misdirected) immune response of the host - post- infectious encephalo-myelitis. Viruses which infect the brain may reach the central nervous system either by the blood stream or by spread along peripheral nerves. Asymptomatic infection of the brain is common. Where a virus infects the brain directly, it can usually be isolated either from brain tissue or from the cerebrospinal fluid. This is not the case with the post infectious syndromes. Acute neurological syndromes There are four main syndromes: 1. Aseptic meningitis 2. Acute flaccid paralysis 3. Encephalitis 4. Post infectious encephalo-myelitis 1. Aseptic meningitis This is the commonest viral syndrome. The condition is self-limiting and has a good prognosis. Infection is confined to the meninges. The clinical features include fever, headache, neck stiffness, photophobia, and vomiting. CSF findings include a pleocytosis consisting of both polymorphs and lymphocytes, but usually with a lymphocyte predominance, normal glucose, and no bacterial growth (hence the term aseptic). Viruses are by far the commonest cause of meningitis. Infections may occur at any age, but are particularly common in children and young adults. Common viral agents include enteroviruses and mumps virus (and less commonly HSV-2 and varicella-zoster virus). 44 CU IDOL SELF LEARNING MATERIAL (SLM)

Sometimes, the underlying brain tissue may also be involved, giving rise to meningo- encephalitis. The prognosis depends on the extent of damage done to brain parenchyma. 2. Encephalitis (grey matter disease) Viral replication occurs in the brain tissue itself, causing destructive lesions in the grey matter. The main symptoms include fever, drowsiness, and confusion, depressed level of consciousness, convulsions, and focal neurological signs. Morbidity and mortality is very high. Viruses that cause this condition include herpes simplex, rabies, and some of the arboviruses. The arboviruses are a miscellaneous group of enveloped, ssRNA viruses that infect animals. They are transmitted from one vertebrate host to another via blood sucking arthropods. The main reservoirs are wild birds and small mammals. Man may be infected if bitten by the insect vector. In South Africa, there are no enzootic arboviruses that specifically cause encephalitis. Rarely, however, encephalitis may occur as part of the clinical course of infection with viruses such as, West Nile virus, Rift Valley fever virus and Sinbis virus. These viruses are enzootic in livestock herds in certain parts of the country and farm workers or vets may occasionally be infected. Rabies: Rabies virus is an enveloped (bullet shaped) ssRNA virus. It primarily infects warm blooded vertebrates. It is enzootic in most parts of the world. Virus is shed in the saliva of infected animals and humans are occasionally infected if bitten by an infected animal. The behaviour of the infected animal is altered and it is more likely to bite humans or other animals that it comes into contact with (thus ensuring the viruses survival). The most common sources of human infection are dogs and bats. Pathogenesis: Virus is introduced into the tissues through a bite. It enters peripheral nerves and travels up the axon to the brain where it replicates. It causes a fatal encephalitis. Incubation period: It varies from 9-90 days, depending on the severity and site of the bite. Incubation period is determined by how long the virus takes to reach the brain. (Bites on the foot take longer than bites on the face.) The disease can be prevented in an exposed person by administration of post exposure prophylaxis in the form of rabies vaccine and rabies immunoglobulin. 45 CU IDOL SELF LEARNING MATERIAL (SLM)

3. Acute flaccid Paralysis This syndrome is due to direct infection of motor neurones (grey matter) in the spinal cord by a virus. Patients present with fever and flaccid paralysis of a group of muscles. Signs of meningitis such as headache and neck stiffness are frequent accompanying features. The most common aetiological agents include the Polioviruses 1, 2 and 3, but with the reduction in prevalence of wild type polio due to successful global vaccination, other (non-polio) enteroviruses are responsible for most cases. (see information on enteroviruses and poliomyelitis) 4 (i) Post infectious encephalitis (white matter disease) This uncommon complication may develop in the convalescent phase, following a number of common viral infections, including measles, mumps, rubella, and primary varicella-zoster virus infection. In addition it may develop following exposure to certain vaccines, such as: vaccinia virus and the older neuro tissue rabies vaccines. Widespread demyelinating lesions develop involving the white matter in the brain and spinal cord. Characteristic histological features include lymphocytic infiltration and perivascular cuffing of adjacent blood vessels. The causative agent cannot be isolated from brain tissue or CSF. The etiology is somewhat obscure, but it is thought to be a T cell-mediated auto-immune phenomenon, triggered by exposure to foreign antigens which are closely related to host proteins normally present in brain tissue (molecular mimicry). 4 (ii) Gillian Barre syndromes This syndrome is characterized by polyneuritis which develops a few days to weeks after the acute phase of a certain bacterial or viral infection. The disease is due to demyelination of peripheral nerves. Patients present with an ascending paralysis, associated with paraesthesia. Like post infectious encephalomyelitis, it is believed to be an immunological phenomenon. Patients usually recover spontaneously over a few weeks or months as affected nerves are re- myelinated. 3. Brain defects or injury: Defects in or injury to certain areas of the brain have also been linked to some mental illnesses. Traumatic brain injury is a leading cause of morbidity and mortality in children, and rates of injury have increased over the past decade. According to a study being presented at the 2018 American Academy of Paediatrics National Conference & Exhibition, these injuries have long-term consequences; researchers found children who experience traumatic brain injury are at higher risk of developing headache, depression, and mental or intellectual disorders up to five years after the event. What is a head injury in children? 46 CU IDOL SELF LEARNING MATERIAL (SLM)

A head injury is any kind of damage to the scalp, skull, brain, or other tissue and blood vessels in the head. A head injury is also often called a brain injury or traumatic brain injury (TBI), depending on the extent of the injury. A head injury can be as mild as a bump, bruise (contusion), or cut on the head. Or it can be a concussion, a deep cut or open wound, broken skull bones, internal bleeding, or damage to the brain. Head injuries are one of the most common causes of disability and death in children. Types of head injuries include: Concussion This is an injury to the head that may cause the brain to not work normally for a short time. Sometimes, this can result in a loss of awareness or alertness for a few minutes up to a few hours. Some concussions are mild and brief, and you may not know right away that a concussion has occurred. Contusion This is a bruise on the brain. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck. In some cases, a contusion may occur on the opposite side of the head because of the brain hitting the skull. This injury can happen from a direct blow to the head, violent shaking of a child, or a whiplash-type injury from a motor vehicle accident. The jarring of the brain against the sides of the skull can cause tearing of the internal lining, tissues, and blood vessels. Skull fracture A skull fracture is a break in the skull bone. There are 4 major types of skull fractures: 1. Linear skull fracture. This is a break in the bone that does not move the bone. Your child may be watched closely in the hospital for a brief time. They can usually go back to normal activities in a few days. No treatment is usually needed. 2. Depressed skull fracture. With this fracture, part of the skull is sunken in where the bone is broken. This may happen with or without a cut in the scalp. If the inner part of the skull is pressed against the brain, this type of skull fracture needs surgery to help correct it. 3. Diastatic skull fracture. This is a fracture that occurs along the suture lines in the skull. These are the jagged lines between the skull bones that grow together (fuse) as a child grows. With this type of fracture, the normal suture lines are widened. These fractures are more often seen in new-borns and infants. 4. Basilar skull fracture. This is a break in the bone at the base of the skull. It can be a serious type of skull fracture. Children with this type of fracture often have bruises 47 CU IDOL SELF LEARNING MATERIAL (SLM)

around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears. This is because of a tear in part of the covering of the brain. A child with this fracture may need to be watched closely in the hospital. Possible complications of a head injury in a child Children who suffer a severe brain injury may lose some function in muscle, speech, vision, hearing, or taste. This depends on the area where the brain is damaged. Long- or short-term changes in personality or behaviour may also occur. These children need lifelong medical and rehabilitative treatment. This may include physical, occupational, or speech therapy. How well a child recovers from a head injury depends on the type of injury and other health problems that may be present. It is important to focus on maximizing your child's abilities at home, school, and in the community. You can encourage your child to strengthen their self- esteem and have independence. 5. Prenatal damage: Effects of prenatal stress can affect children into adulthood If we want to understand child development, we need to start before birth. We have known for decades that health depends on an interaction between our genes and our environment. But we’ve also come to realize that a key part of that environment is in the womb before we’re born. There is now considerable evidence that the mother’s emotional state during pregnancy can affect the development of her baby’s brain. This is because of “fetal programming”, where a changing environment in the womb through different sensitive periods can alter the development of the foetus. This then goes on to affect the child in the longer term and into adulthood. This is clearly important in physical health; if a baby grows less well than it should in the womb, he or she will be at greater risk of coronary heart disease or diabetes in later life. But there is now considerable evidence that fetal programming is also important for neurodevelopment in the brain. Kinds of stress “Stress” is a generic term, which includes a number of different types of exposure. Many exposures, varying from mild to very severe, have been shown to affect outcomes for the child. They can include symptoms of maternal anxiety and depression, pregnancy specific anxiety, daily hassles, bereavement, life events, bad relationships, and exposure to acute disasters. 48 CU IDOL SELF LEARNING MATERIAL (SLM)

Our research showed that a child’s risk of developing emotional or behavioural problems doubles from 6% to 12% if its mother is stressed, anxious or depressed. Although this means that most children will not be affected, this increased risk is of clinical significance. One important question is whether or not these associations between prenatal stress and altered outcomes are causal, i.e. directly linked, or whether the associations are due to other factors. For example, mothers who are anxious, depressed or stressed prenatally can continue to suffer these issues after the baby is born. This can also affect their parenting. Factors such as smoking, drinking alcohol and hereditary genetic defects may also play a role. There are various ways of addressing the question of causality. Studies using animals have been conducted, where offspring were cross fostered to eliminate parenting problems as a cause. This model also showed that prenatal stress causes behavioural alterations in offspring. How stress reaches the womb Our group wants to discover the underlying mechanism that causes this association. One possibility is that the foetus is exposed to increased amounts of the stress hormone, cortisol. This has been shown in animal studies. And our research found that exposure to raised cortisol levels in the amniotic fluid is associated with lower cognitive function in the child later on. We also recently proved that the function of the placenta changes in association with maternal anxiety. Essentially, we noticed a decrease in the enzyme that breaks down cortisol, potentially allowing more cortisol to pass through the placenta and affect the baby’s development. We’re only just starting to understand these possible mechanisms. Many other systems are likely to be involved, for example the role of serotonin, a neurotransmitter that transmits signals in the brain and which is known to affect fetal neurodevelopment. Most anxiety, depression and emotional and physical abuse experienced by pregnant women remains undetected by health professionals. Even when the symptoms are recognized, it can be difficult to get help. To counter the harmful effects that stress has on a developing baby, we need to be more aware and provide more emotional support. 6. Substance abuse: When teenagers are struggling with emotional problems, they often turn to alcohol or drug use to help them manage painful or difficult feelings. In this they are not different from adults. But because adolescent brains are still developing, the results of teenage “self- medication” can be more immediately problematic. 49 CU IDOL SELF LEARNING MATERIAL (SLM)

In the short term, substance use can help alleviate unwanted mental health symptoms like hopelessness, anxiety, irritability, and negative thoughts. But in the longer term it exacerbates them, and often ends in abuse or dependence. Substance use escalates from experimentation to a serious disorder much faster in adolescents than it does in adults, and that progression is more likely to happen in kids with mental health disorders than in other kids. “The rule of thumb is that almost half of kids with mental health disorders, if they’re not treated, will end up having a substance use disorder,” explains Sarper Taskiran, MD, a child and adolescent psychiatrist at the Child Mind Institute. A 2016 study of 10,000 adolescents found that two-thirds of those who developed alcohol or substance use disorders had experienced at least one mental health disorder. Why are kids with mental health disorders prone to substance use? Kids who are anxious or depressed may feel more emotionally “even” if they drink or smoke marijuana. For socially anxious kids, it can quiet the anxiety enough to allow them to function in peer groups. And since their friends do it, it’s not stigmatized the way taking medication is. “Pre-gaming is a lot about anxiety,” notes Jeanette Friedman, MSW, who works with families of adolescents with substance use problems. “The kids are saying ‘Let’s go have some fun before we go to the real party.’ But in fact, most of them feel like they need it to calm down enough so they can walk into a group where they’re going to feel exposed and criticized.” A teen with anxiety might start by smoking marijuana to calm down before social events, and soon find himself smoking every morning just to get to school. “I’ve had very stressed-out kids say, ‘I get high before I go to school because I’m so anxious when I think about the start of the school day,’ says Ms. Friedman. “‘If I smoke a little weed, I don’t feel so anxious.’” Kids who are depressed may use alcohol or marijuana to cheer themselves up, Dr. Taskiran notes, and blunt the irritability that is a symptom of adolescent depression. “They know there’s something wrong with them,” he says. “They’re not taking pleasure in things; they’re not feeling happy. So if their peers are offering a drug that makes you happy, that’s often the first thing they turn to.” Substance use can quiet negative thoughts that plague depressed kids. It’s also common for children with mental health or learning disorders to develop self-esteem problems, a sense that there’s something wrong with them or that they’re flawed. When these children reach adolescence, with its focus on fitting in, notes Ms. Friedman, “they really want to be normal and they don’t feel normal. And that means they’re more vulnerable to somebody passing around a drug, because they’re just trying to feel better.” Why does alcohol use riskier for teenagers? 50 CU IDOL SELF LEARNING MATERIAL (SLM)

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